Is it safe to use Seroquel (quetiapine) during the 3rd trimester of pregnancy in a woman with a history of psychiatric illness?

Quetiapine (Seroquel) Use in the Third Trimester

Quetiapine can be continued during the third trimester if the benefits of treating the mother's psychiatric illness outweigh the risks, but neonates require close monitoring for withdrawal and extrapyramidal symptoms in the first 1-2 weeks after delivery. 1

FDA Classification and Key Safety Data

• Quetiapine is FDA Pregnancy Category C, meaning animal studies show embryo-fetal toxicity but there are no adequate well-controlled human studies 1
• Limited published data from 63 exposed pregnancies (21 prospective, 42 retrospective) showed no major malformations associated with quetiapine exposure 1
• The largest prospective registry study of 264 quetiapine-exposed pregnancies found a malformation rate of 1.85%, comparable to the control rate of 1.77% (OR 1.04,95% CI 0.38-2.85), with no specific pattern of defects 2

Third Trimester-Specific Risks

Neonates exposed to antipsychotics including quetiapine during the third trimester are at risk for extrapyramidal and/or withdrawal symptoms following delivery. 1

Expected Neonatal Complications:

• Agitation, hypertonia, hypotonia, and tremor 1
• Somnolence, respiratory distress, and feeding disorders 1
• Jitteriness and irritability 3
• Symptom severity varies: some cases are self-limited while others require intensive care unit support and prolonged hospitalization 1

Clinical Management Algorithm

Decision to Continue Treatment:

• Continue quetiapine if psychiatric stability requires it, as untreated maternal psychiatric illness carries significant risks including relapse, poor prenatal care, and postpartum decompensation 1, 4
• Use the lowest effective dose to minimize fetal exposure while maintaining maternal stability 1
• Do not abruptly discontinue in the third trimester, as this increases risk of maternal relapse which poses greater overall risk to the mother-infant dyad 4

Perinatal Planning:

• Inform the pediatric/neonatal team about maternal quetiapine use prior to delivery 1
• Arrange for early postnatal monitoring of the infant for at least the first week of life 3
• Monitor specifically for: respiratory distress, feeding difficulties, tremor, irritability, hypertonia/hypotonia, and somnolence 1, 3

Postpartum Monitoring:

• Most neonatal symptoms appear within hours to days after birth and typically resolve within 1-2 weeks 3
• Symptoms may represent either direct drug effects or withdrawal-emergent syndrome 3
• In severely affected infants with persistent symptoms, supportive care is the mainstay; specific pharmacologic interventions are rarely needed 3

Important Caveats

• The risk-benefit analysis must account for the severity of the mother's psychiatric condition and response to alternative treatments 1
• There is insufficient data on long-term neurodevelopmental outcomes in children exposed to quetiapine in utero 1
• Quetiapine is excreted in breast milk (infant dose 0.09-0.43% of weight-adjusted maternal dose), requiring a separate decision about breastfeeding 1

The decision to continue quetiapine should prioritize maternal psychiatric stability, as untreated severe mental illness poses documented risks to both mother and fetus that likely exceed the transient neonatal adaptation issues associated with third-trimester exposure. 1, 4